Application Form Applicant InformationApplicants are considered for all positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, I or any other prohibited basis of discrimination, as provided under applicable state and federal law.Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone #*(including area code)General Work HistoryHave You Ever Been Employed By Friendship Haven, Inc.?* Yes No If yes, under what name? Date Last Worked Position Held Reason For Departure Position For Which You Are Applying?* Expected Wage When Can You Start? Hours You Would Like To Work Per Week?*5-15 Hours/Week15-30 Hours/Week30-40 Hours/Week40 Hours/WeekShift Preference* Morning Afternoon Night Are You Willing To Work Weekends?* Yes No Are You Willing To Work Holidays?* Yes No What/Who Prompted You To Apply Here? List Any Relatives That Work Here If Under 16, Can You Obtain a Permit To Work? Yes No Not Applicable Are you physically and mentally able to perform the essential functions of the job for which you are applying with or without reasonable accomodation?* Yes No If No, Please Explain Do you have a record of founded child or dependent adult abuse in this state or any other state?* Yes No If Yes, Please Explain Have you ever been convicted of a crime, in this state or any other state?* Yes No If Yes, Please Explain A conviction record will not necessarily be a bar to employment. Factors, such as age and timing of offense, seriousness and nature of the violation and rehabilitation will be taken into account.Do you have a nursing license?* Yes No Type of License RN LPN Registration # StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you a certified nursing assistant?* Yes No If hired, can you furnish proof that you are eligible to work in the United States?* Yes No If unsure of the documents needed to prove eligibility to work in the U.S., we will be happy to explain the legal requirements.If No, Please Explain Educational HistoryHighest Level of Education Completed* Grade School High School College Graduate School Business/Technical High School*High School/LocationCourse/MajorGraduated (Yes/No) CollegeCollege/LocationCourse/MajorDegree (Yes/No) Business, Technical, Night or Correspondence/LocationSchool/LocationCourse/MajorDegree (Yes/No) Employment HistoryPlease begin with the most recent.May we contact your present employer?* Yes No Employer*CompanyTelephoneAddressJob TitleSupervisorJob DescriptionSalaryReason for LeavingStart DateEnd Date EmployerCompanyTelephoneAddressJob TitleSupervisorJob DescriptionSalaryReason for LeavingStart DateEnd Date EmployerCompanyTelephoneAddressJob TitleSupervisorJob DescriptionSalaryReason for LeavingStart DateEnd Date ReferencesPlease list names, addresses and telephone numbers of the three persons other than relatives and employers with whom you are acquainted.Reference #1*NameHow do you know them?AddressPhone # Reference #2*NameHow do you know them?AddressPhone # Reference #3*NameHow do you know them?AddressPhone # Additional InformationComments/QuestionsUse this space to provide any additional information that might be useful in considering you for employment.Attach an Optional RésuméAccepted file types: pdf, docx, Max. file size: 256 MB.(PDF or Word Doc)Attach an Optional Cover LetterAccepted file types: pdf, docx, Max. file size: 256 MB.(PDF or Word Doc) Δ
